Health-System Meltdown

CAN HEALTH CARE FOR THE POOR AS IT NOW exists be saved in Los Angeles County?

The answer looks like "no." Even the Department of Health Services' (DHS) usual strong supporters -- Supervisor Gloria Molina, for instance -- seem resigned to an "inevitable" downsizing that will make for longer lines at fewer facilities. Or as the Times quoted her, speaking of her own constituents: "They're just going to have to drive farther, wait longer."

This also means that more poor people will stay sick longer and that fewer will seek health care before their conditions are extremely serious. In the long run, that means that more people will die. No one knows yet how many.

But this is a classic matter of lives vs. money, and money -- or its absence -- talks louder. There's an $800 million county shortfall coming due over the next three years. And we've just seen the windup of the more than $1 billion in a federal health-aid program that's been bolstering the system since 1995. County leadership's taken it in the neck from health-care unions for not demanding more federal and state health-care money for this budget. But none of these critics has said how such money could
be found.

The Health Services Department contends that, before it collapses on its own, the current system must be deflated into something the county can afford. And down to something that can -- it is optimistically proposed -- concentrate what services are left on the county's least-served populations.

Or that's the avowed plan of Thomas Garthwaite, M.D., the highly salaried, former VA official who took over DHS early this year. With the Board of Supes apparently surrendered to the inevitable, the question now is, will they also take to the other Garthwaite changes? These are changes that he is offering as organizational, but which, to put it bluntly, cut the supervisors' power over health services in their districts. Some business-as-usual politics are already visible in the proposed new mix, and we shall refer to them later. But other Garthwaite changes seem intended to depoliticize the process by centering the caregiving around L.A. County­USC Medical Center and closing or scaling down such outlying installations as High Desert Hospital. This could, in the long run, result in the transformation of what's been a randomized network into a coherent organization.

As Garthwaite recently put it in a board paper, "Historically, DHS has not functioned as a system, but rather as a collection of largely independent facilities and health-care programs." Garthwaite speaks of the current absence of "a system perspective" whereby, for instance, hospitals would (with board approval) add costly new facilities duplicating those of the other DHS hospitals.

But much of this ill-coordinated independence stems from supervisorial fiefdoms: Even low-voting populations like shiny new clinics, and supervisors, like most legislators, rarely oppose a project wholly in another's district.

PART OF THE PROBLEM IS ALSO HISTORICAL. The Los Angeles County public hospital system nowadays mostly treats indigents: It was designed to treat everyone. Or nearly everyone. The department's USC-linked centerpiece medical center was constructed early in the last century for the majority of residents who couldn't afford fancy private hospitals like Cedars of Lebanon.

Thus was born the televised myth of General Hospital as a symbol of L.A. public medicine's competence and egalitarianism -- kind of like Dragnet in white. The fact that most county patients could then afford to pay their bills helped keep the entire system solvent.

A lot of things have happened since then, though: Health care got more complex, and people wanted better care than the county could offer. Health insurance became more common. Proposition 13 arrived in 1978, just before the 1980s' huge wave of immigration. It halted tax increases that could have otherwise bolstered indigent care.

Now that roughly two-thirds of the population has some kind of health insurance, most of us never see the inside of Big County unless the ambulance drops us at the ER. But nearly 800,000 less affluent people -- in- and outpatients -- used county hospitals and clinics last year. And three-quarters of those had no health insurance. According to Garthwaite, about 31 percent of these inpatients and 60 percent of the outpatients couldn't pay their bills (in some clinics, non-payment was around 88 percent, others say). The cost to the county was in the hundreds of millions. That's a big part of the shortfall.

How bad are the cuts going to be? Deep enough, in the worst scenario of three proposed, to reduce the number of these inpatients by 39 percent and outpatients by 72 percent. Garthwaite admits this is a formula for public-health disaster. But that's what the county faces under its current finances without major changes to the system, Garthwaite says.

The worst-case plan basically shuts down almost everything but Big County; in what Garthwaite calls Scenario II, one additional county hospital stays open, while the other four are chopped down to "ambulatory care centers" for outpatients or spun off. Many clinics are closed. This plan, says Garthwaite, provides far better service than the first at roughly the same cost, but requires major reorganization of services. This Garthwaite called "as rational an approach to change as you can take.'' It is the one he is pushing hardest, although he admits that no possible reorganization can keep up the current levels of service. Perhaps the most devastating immediate effect will be on the "public-
private partnerships" DHS encouraged through the late '90s, with nonprofit clinics all over the county. Many of these charitable institutions now wonder how they will survive without county help.

The third alternative looks like the current system cut down and run on a more efficient basis, but this "scenario" would require infusions of state or federal money that no one sees coming in right now. And -- as under the two other plans -- DHS psychiatric care could be eliminated. Garthwaite's basic hope is that if the county can pull off Scenario II, it then will be in a far better position to ask someone -- Gray Davis or George W. Bush, for instance -- for some extra help to advance to III. "There's a feeling that the county didn't do enough to change itself in the past," he says. Which understates the mess left behind by his two predecessors.

Now for the politics. The extra hospital that Scenario II keeps open happens to be the system's most notorious -- King-Drew Medical Center, which the latest state audit calls the worst in the DHS system. The plan proposes to turn into a day clinic the hospital that the audit calls the system's best -- Harbor UCLA Medical Center. Why is this? Both lie in Supervisor Yvonne Brathwaite Burke's 2nd District. Burke, many allege, favors King over Harbor, partly due to its cultural importance in the African-American community.

Garthwaite claims that he's keeping King because it serves a larger, poorer area, one "with very few other hospitals and . . . a lot of trauma cases." His scenario requires King to upgrade its efficiency by 16 percent over the next three years. That's a fine idea, but county officials have been saying "Heal thyself" to the problematic K-D for at least a decade. So excuse my skepticism.

In the end, though, the greatest effect will be on the hundreds of thousands of indigent patients who use the far-flung county clinics every day -- even those that manage to stay open. Hugo Almeida, administrator of the county's El Monte Comprehensive Health Center, says that closing adjacent clinics will bring up his patient load by well over 20 percent, to more than 134,000 visits per year.

"People with families will take longer to get here, they'll have to spend more time on public transportation with more transfers." As to how his staff will handle the increased patient load? "I don't specifically know how they will."